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Why does the general practitioner refer patients with chest pain not-urgently to the specialist or urgently to the emergency department? Influence of the certainty of the initial diagnosis

Background - Chest pain is an initial symptom for several minor diseases but acute myocardial infarction (AMI) should not be missed. Aim - To assess the influence of initial diagnosis and degree of certainty of this initial diagnosis on the referral decision and the referral method (urgent - non-urgent) in patients contacting their GP with chest pain. Study design - Observational study. Setting - The study was performed in a sentinel network of general practices in Belgium, covering almost 1.6% of the population. Subjects - All patients attending their GP and complaining of chest pain during 2003. Method - The relationships were reported as proportions and in odds ratios (OR) with their 95% confidence intervals. Results - 1996 patients were included (men 52%). Men were referred more often (OR = 1.44; 95% Cl: 1.13-1.82). Age shows no relation to referral (OR= 1.06; 95% Cl: 0.83-1.35) but predicts urgent referral (OR = 1.46; 95% Cl: 1.02-2.08). Odds ratios in case of serious heart disease were high with 11.58 (95% Cl: 5.72-23.44) when the GP was certain of his diagnosis and 2.96 (95% Cl: 1.59-5.51) if not. If the GP was uncertain, in all disease categories 54% (95% Cl: 48-59) of the patients were referred non-urgently. Conclusion - Referral rates for patients with chest pain were influenced by the initial diagnosis and the degree of certainty of this initial diagnosis.